- Dr Simon Moore MD CCFP
Five Things Not to Miss: Limb Injury
Don't miss: Abnormal Vitals
Missed abnormal vital signs are a huge source of liability. When working in ER always either circle the provided vital signs, or re-write them in the physical exam note, or take the vital signs yourself – this is even more important if a patient presents with a seemingly unrelated injury (or if you'e on an OSCE!).
A patient with a sore joint and a fever is a very different scenario than a patient with a sore joint. As well, a patient with a leg fracture, hypovolemia, and tachycardia obviously makes you think of something much more serious than just a leg fracture. But if you look at the x-ray before looking at the patient or the vital signs, you could easily miss that. Don’t forget the vital signs – they’re vital!
Don't miss: Hidden fractures
If your patient presents with a wrist injury, you do not want to miss a scaphoid fracture. Do a good history and exam so that you don’t miss this – ask about FOOSH, look for pain over the snuffbox, pain on axial loading, or inquire about a suspicious mechanism. Clinical suspicion is key - even if the radiograph shows no fracture (which is quite possible as x-rays are only 11% sensitive).
If you have high clinical suspicion, then place the patient in a volar splint and obtain further imaging and follow-up (and document). For example, get imaging again in 3 days. It’s helpful to know all of the imaging options for your exam: CT, MRI, Bone Scan with MRI, or bone scan – and that bone scan is the gold standard.
Pro tip - Don’t forget to ulnarly deviate the wrist to expose more of the scaphoid when you palpate the snuffbox, as this can help you complete a more thorough exam.
Don't miss: Distracting injury
It would be unfortunate to take exceptional care of a patient’s finger sprain and miss the fact that they have a dislocated shoulder. Taking a thorough history, and completing a thorough physical exam (especially if the patient is intoxicated or unable to provide a good history) is crucial to ensuring that you don’t miss anything.
Remember to ask, “What else could this be?” And with any open or dirty wound consider tetanus prophylaxis, whether you’re in a written exam, verbal exam, or clinical practice.
Don't miss: Neurovascular compromise
A broken bone can easily distract from a compromised artery or nerve. Every limb injury should have a documented pulse, especially when it is an injury that is high risk for vascular compromise such as a humeral neck fracture. Always remember to consider compartment syndrome, especially in high risk injuries like burns or large bone fractures - especially tibia.
Don't miss: The Second Fracture
The most commonly missed fracture! Be sure to scour the radiograph and assess all points of increased tenderness. As well it’s rare but sometimes you will even find an unexpected third fracture. You will hardly ever find it if you don’t look for it.